Stefanie Green didn't enter the medical field thinking she would end up helping Canadians end their lives. In fact, she spent much of the earlier part of her career on the other end of the lifecycle, in the maternity ward, helping mothers give birth.

Speaking at the medical campus of the University of Auckland on Thursday, Green told a gathering of students and clinicians that she had been directly involved in 150 assisted deaths since Canada first passed euthanasia legislation three years ago.

Green's visit coincides with the successful second reading of the End of Life Choice bill and her experiences provide a glimpse at what life might be like for the doctors who will have to carry out the tough job of helping people choose when they'd prefer to die.

Last night, David Seymour’s End of Life Choice Bill took a step closer to becoming law. Photo/Getty.

The healthy majority for the End of Life Choice Bill coming so soon after Victoria’s law passed will ring alarm bells for opponents on both sides of the Tasman.

Last week, a quarter of Australia’s population became eligible for an assisted death if they are terminally ill after the implementation of Victoria’s Voluntary Assisted Dying Act. And last night, on this side of the Tasman, David Seymour’s End of Life Choice Bill took a step closer to becoming law.

The bill passed its second reading with a clear margin — 70-50. It was a slimmer majority than at the first reading in December 2017 — which passed 76-44 — but it is an extraordinary result given the extensive campaign mounted against it over the past 18 months.

The loose coalition of religious and quasi-religious groups which spearheaded the offensive to kill the bill has good reason to be worried about the outcome. There is a real prospect of a domino effect across Australia and New Zealand.

Opponents fear that now Victoria’s act is in operation and many of the practical details of how it will be implemented have been worked out, advocates and voters across Australia and New Zealand will be emboldened and push even more strongly for changes in their jurisdictions.

Assisted dying campaigner Dr Philip Nitschke described the knock-on effect of Victoria’s law change in Australia: “It will put a lot of pressure on the other state Parliaments to pass legislation. You can’t have people in NSW pressing their noses against the glass saying, ‘How come Victorians have got this choice and we don’t?’.”

The effect will reverberate across the Tasman too as the debate continues in New Zealand in the lead-up to the third reading. Many New Zealanders will also think: “If Victorians have this choice, why not us?”

Opponents often try to illustrate the dangers of assisted dying by using examples from faraway countries like Belgium and The Netherlands with very different cultures to our own, but Victoria is very close to home. And more than 80,000 New Zealand-born expats live there. Those who have Australian citizenship or permanent residency, and who have lived in the state for a year, are now eligible for an assisted death if they are terminally ill.

Opponents — particularly the Catholic church — can’t afford to allow another defeat in New Zealand or Australia, and Seymour’s bill passing its second reading means their alarm bells will be jangling very loudly.

That rising level of alarm was evident in Maggie Barry’s advance warning a few days ago that she intends to introduce around 120 amendments when the bill is debated in the Committee of the Whole House. She had obviously counted heads and knew it would easily pass at its second reading — even though she asserted: “What I can say with certainty is that the gap is extremely narrow.”

Her proposed avalanche of amendments is widely viewed as an attempt to filibuster as much as she can — perhaps in the hope that the bill won’t get through Parliament in time for it to be put to a binding referendum at next year’s election.

David Seymour told NOTED he recognises that as a possible “danger” but he doesn’t believe it will be a viable strategy in practice: “Opponents will find it much more difficult than they think to keep it going that long.”

However, even if Barry’s tactics don’t succeed in warding off a referendum next year, or killing it at the third reading, she will be hoping to make the bill so restrictive that it will be very difficult for the dying to access its provisions — which is a criticism that has already been made of Victoria’s legislation, which has 68 safeguards.

Now that advocates are wise to that tactic, however, they are less likely to settle for the same in New Zealand, or in the Australian states where activists are pushing hard for a law change.

Western Australia isn’t far behind New Zealand. A government bill is scheduled to be introduced in August after a cross-party parliamentary inquiry strongly recommended in 2018 that one be introduced — and the eligibility criteria and conditions the MPs proposed in their report look very much like those of the bill Seymour placed in Parliament’s biscuit tin in 2015.

A bill similar to Western Australia’s will be tabled in New South Wales, probably by year’s end. Tasmania’s Parliament will also vote on the issue in 2019 with the legislation having support in principle from both Houses.

Queensland and South Australia are both running inquiries into end-of-life choices and there is a renewed push to allow the territories of ACT and NT to determine their own assisted dying laws (after that right was removed from the Northern Territory in 1997 to quash its pioneering law three years earlier).

While public support in New Zealand has run for years at more than 70 per cent, in Australia support in polls has recently come close to 90 per cent, according to an ABC Vote Compass poll of 450,479 respondents taken before the federal elections in May — which makes opposition by Australian MPs look completely out of touch with their electors.

In the wake of Seymour’s parliamentary success, New Zealanders can expect to see a lot more of the kind of tactics opponents used in the long run-up to Wednesday’s vote — including slick video campaigns, newspaper ads and plain old-fashioned scaremongering — but at an even higher pitch.

Opponents are going to be in a bind, however. Much of their opposition to Seymour’s bill over the two years since it was plucked from the ballot in June 2017 has centred around the clauses allowing eligibility to those with a “grievous and irremediable medical condition” who suffer from “an advanced state of irreversible decline in capability”.

He recommended restricting eligibility to the terminally ill with six months or less to live (or 12 months for those with a neuro-degenerative disease) as well as adding the express rider that disability or mental illness alone would not qualify anyone for an assisted death.

Seymour’s unexpected move to restrict the terms of eligibility put arch-opponent Maggie Barry into an obvious flap. It was immediately clear to her that in one fell swoop the Act MP had dramatically shifted the goal-posts and the wind could easily turn sharply against her and other prominent opponents — including Disability Rights Commissioner Paula Tesoriero, who has argued that the disabled are at risk of being forced into an assisted death.

Consequently, Barry was quick to point out that the bill was no longer Seymour’s property, and any changes he might suggest are only recommendations. It is true that he is technically now only a passenger watching his own bill’s progress but, unfortunately for Barry, as its sponsor he has a lot of moral authority over how it is framed.

The other obvious bind that opponents will find themselves in now the bill has passed its second reading is Seymour’s proposed amendment for a referendum at the next election before it becomes law — a condition that NZ First has placed on its continued support.

Any MP who doesn’t vote for that amendment risks looking very undemocratic, to say the least, given that a substantial and consistent majority of New Zealanders have wanted a law change to allow some form of assisted dying for more than 20 years.

Politicians might well find that the public are increasingly intolerant of MPs who won’t agree to a referendum — especially once its scope is restricted to only the terminally ill, and disability and mental illness are explicitly ruled out as grounds for eligibility, as seems likely.

If opponents’ major objections are answered — in particular by removing the “grievous and irremediable” clause — why would they go on thwarting what the public have so clearly demanded for a very long time?

We must give ourselves a couple of days to celebrate and then get ready for the next round.

Firstly, my deepest thanks to all the people who worked so hard – especially Maryan Street and David Seymour, without whom we would not have reached this position. But in addition, so many people – members and supporters, put in an enormous effort and then shared their joy with us online since the vote. How wonderful it was to read your comments and I’m sorry I could not reply to everyone who sent in emails.

Facing the fight from here, we must keep up the struggle to get a law passed that will be functional and provide relief to those who are dying. We must keep watching the situation in Victoria where some of their legal absurdities are just emerging – it now appears that a doctor could be accused of a federal crime if they discuss Assisted Dying via the phone or Internet with a patient they are already advising! While this is very unlikely, it will worry some doctors before this situation can be resolved. Then there will be the filibustering of our opponents to contend with.

Many other barriers raised in the next few months but each one we can confront if we keep working together. We will be resilient and continue our successes.

OPINION: David Seymour and other backers of assisted dying will be celebrating after his long-fought End of Life Choice Bill made it through its second reading on Wednesday night.

Seymour's bill passed by 70 votes to 50, a slimmer margin than it did at first reading in late 2017, but well above the 61 votes required.

The vote followed 20 emotive speeches from MPs, many of whom mentioned close ones they had seen die in painful ways.

KEVIN STENT/STUFF David Seymour will be celebrating tonight but a huge fight remains.

Labour and National MPs were allowed to vote according to conscience, while NZ First and Green MPs all voted in support as a bloc.

The victory will frustrate the strong lobby which has campaigned relentlessly against the bill over its marathon legislative process, a lobby with unlikely bedfellows such as former Prime Minister Bill English and Human Rights lawyer Deborah Manning.u

So the various amendments Seymour needs to make for the bill to pass will not be implemented in the tidy private process of the select committee, but in the messy and extremely public committee of the whole house, which takes place before the third reading.

This narrowing is likely to pass, but whether it ends up going far enough to keep enough people on board will be hard to tell: It's very hard for a party like the Greens to ignore outrage from the disability community.

Seymour has agreed to support the referendum, but 61 votes for the amendment will be needed, and many MPs might not be keen on such a controversial issue being tacked on to the 2020 election. Those who are deeply against the bill might have the most reason, as most polling shows a referendum would likely see the bill become law.

It's quite unclear what would happen with NZ First's nine votes if the referendum is not inserted - MPs have differing ideas, and no NZ First MP made a speech on Wednesday night. If all nine voted against the bill it would almost definitely fail. But if the caucus decided to abstain, or allowed its MPs to vote their conscience, the bill could still have a strong shot.

The committee stage will also allow deeply opposed MPs many opportunities to frustrate the process, seeking to pass amendments that nullify the bill or make it so loose as to lose votes.

This is not the US Senate and the Speaker can stop too much mischief-making. But since the bill will only progress during fortnightly members' nights, it could still take a long while.

Their rarity and the strong emotions they can rouse mean they are embedded deeply into history. Short-term political gain can lead to long-term historical shame. The words of those who opposed Homosexual Law Reform followed them for decades. The debate that MPs will have over the following months will follow them too.

* Originally the vote was declared by the Speaker as a 70-51 result, but was later corrected to 70-50.

Assisted death advocate Matt Vickers, former prime minister Sir Bill English and wife Dr Mary English fronted a parliamentary hearing on the End of Life Choice Bill in August.

OPINION: This week MPs will decide whether the End of Life Choice Bill will pass second reading. It has been over four years since my late wife Lecretia Seales pursued a choice about how she died. It has taken a long time and a lot of work to get to this point.

Lecretia was a law reformer and well respected amongst the legal community. She worked for two prime ministers: Sir John Key, as a justice advisor, and Sir Geoffrey Palmer QC, as a senior legal advisor at the Law Commission. She knew exactly what she was asking for, and its legal implications, and she would be pleased with the End of Life Choice Bill, which has been crafted with the assistance of lawyers who acted for Lecretia in Seales v Attorney-General.

Those lawyers have been steeped in this issue for years and have a deep understanding of how the laws work overseas. They are this country's legal experts on this issue. And despite misrepresentations from opponents, this bill stands up as one of the best examples of all of them, tailored to the needs of New Zealanders.

It is smart, robust, and evidence-based law.

MATT VICKERS | Matt Vickers and Lecretia Seales in 2010.

Palliative care is a wonderful thing, but like medicine, it is not perfect. Justice David Collins, in his ruling on Lecretia's case, accepted this fact based on the evidence presented by both parties. So the question becomes: what do we do if we know that palliative care cannot deal with all suffering? Do we just accept that some people will suffer awful deaths, turn away from them, and decide that those people are just unlucky? Or do we listen to them, show compassion, and allow those people to have a choice about how they die?

The End of Life Choice Bill offers people that choice, which I believe is the only humane thing to do. Next month, at a memorial lecture I have organised in my wife's name, a philosophy professor specialising in ethics from Harvard University will visit New Zealand to discuss the moral permissibility of offering these sorts of choices.

Should the bill pass second reading, we will see amendments proposed by MPs for tightening the wording and the criteria. In fact, the Ministries of Justice and Health have already been providing input to amendments to address all the concerns of opponents.

MONIQUE FORD/STUFF | Matt Vickers submits on the End of Life Choice Bill at a select committee hearing in August.

The sponsor's amendments will restrict access to those that are terminally ill, and in an advanced state of decline, and who are suffering unbearably. Despite the claims of opponents, the bill will not allow people to access assisted dying on the basis of a disability alone. No one wants that. I certainly don't support that, and neither would Lecretia. It will bring the law into line with the one that just came into effect in Victoria, Australia, which is regarded as the most rigorous assisted dying regime in the world.

New Zealanders deserve to see the final bill, what the criteria would be, and who would be affected. So let's support the bill, get to a final drafting, and then talk about what it will mean before a final vote later this year.

SUPPLIED | Matt Vickers is looking forward to the second vote on the End of Life Choice Bill next week.

If the bill was voted down at second reading, that would be MPs denying New Zealanders an opportunity to see the bill's final wording, which would be a terrible disservice to the public, and to Lecretia's supporters, who have worked incredibly hard to see this issue considered after decades of parliamentary inaction. Support for assisted dying runs anywhere between 65 and 75 per cent, depending on who is doing the polling.

Our elected representatives know assisted dying is well supported by their constituents and therefore have a duty to give this bill the best chance of success.

MPs that vote yes on Wednesday are not only voting in support of assisted dying, but in support of representative democracy itself.

The euthanasia debate is progressing, with the End of Life Choice Bill expected to have its second reading in Parliament on Wednesday. A similar bill was passed in Canada in 2016 - and it's estimated about 8000 people have had a medically assisted death there. Dr Stefanie Green is President of the Canadian association of doctors and nurses who provide euthanasia services.

Dr Stefanie Green: Thanks for having me.

First of all, you’re a doctor, so how do you reconcile pro-euthanasia views with the spirit of being a doctor?

I think it’s absolutely consistent. No matter what we say at our medical school interviews, most of us go into medicine to help people, and this is another form of helping people at a really vulnerable and terrible time in their lives.

So what do you say to the New Zealand Medical Association’s stance that they say euthanasia in any form is unethical?

I think that’s naïve, to be perfectly honest. I think that when someone is suffering intolerably at the end of their life and we have a legalised medical service that allows for us to help them in that moment. When a competent adult asks me to help them, I feel like I’m helping them by doing that.

And you have done that roughly 150 times, you personally have been involved in medically assisted death, or MAID, as you call it, in Canada, haven’t you?

Yes, I’ve had the privilege of helping 150 people end their life.

Is it a privilege, is it?

Oh, it’s a sincere privilege. It’s a very intimate time for someone. It’s a privilege to witness them through that journey, to support them through that journey, to offer them a care that they’re desperate for and to be able to grant them that and to help them do it in a very comfortable way, it’s a huge privilege.

Does this normalise the process? Does it normalise the idea of assisted suicide?

I don’t think ‘normalises’ is the right word. I think accepting it as another form of care at the end of life, as another end-of-life care option. There are many, and it is only one, and only 1.5 per cent of all Canadians’ deaths are chosen to be in this way. It’s a very small number still, but I think it’s important.

Let’s talk about your experience. In the people that you have assisted, has it always been peaceful?

In the people that I have assisted, it’s always been peaceful. Absolutely, because it’s a controlled procedure that I am there to make peaceful.

And how long does it take?

Well, the majority of assisted deaths in Canada are actually by clinician administered medication, which is what I’m doing. And so, technically, from the initial administration to the end of the procedure and the end of heartbeat, it’s, on average, about 10 minutes.

Most of it is clinician assisted. Do people actually self-medicate?

There is the option in Canada legally to self-medicate. We’ve had very very few – I’d say probably under 20 cases in 8000. I’ve been involved in one. It takes a little bit longer. It’s also peaceful, but it’s a different process.

Because there is that concern here that it doesn’t always go according to plan and that the death is not peaceful. Have you come across this at all?

I have actually not come across that at all. The protocols in Canada we use are based on the Dutch protocols. They’re very very effective. We lobbied very hard with my group CAMAP to have the proper medications available so that we could have a lesser time to dying and a more comfortable experience, and so it’s been good.

Okay. Why shouldn’t high quality palliative care be the answer to people who are at the end of their life?

High quality palliative care is essential. I think that we need to lobby for that. I’m all in favour of that. I’m very lucky where I live my work is very well integrated with palliative care teams. It’s essential for our patients to have that. But we all know that palliative care cannot address every single event, and there are patients that suffer at the end that palliative care cannot help.

Right, so it’s true that palliative care cannot ease every point of suffering.

Of course not.

Okay.

Every palliative care doctor will tell you that, and if they don’t say so, they’re being disingenuous.

At what point do you say you can’t help someone? If someone comes to you and they have very poor quality of life, but it’s not an irreversible disease or symptom, what do you say to them?

That’s probably the hardest thing of what I do. We have very strict eligibility criteria in Canada that must be rigorously found to be true, and if somebody comes to me suffering at the end of their life with a chronic disease or a chronic pain that they’ve had for many years but they don’t meet all of our criteria, I can’t help them. That doesn’t mean they’re not suffering. That doesn’t mean I don’t want to, but I have to work within the law and so I need to explain to them that I believe what’s happening to them is horrible, but I’m not legally allowed to help them, and I have to help them try and find other resources.

You’re the president of the Association of the Doctors and Nurses that help provide these services. Do your members need counselling?

We offer support systems to our members. There’s a number of different regional resiliency programmes. We do find, though, and early Canadian data is showing a little bit to our surprise that the attitudes and experiences of people providing this care has actually been fairly positive. People find this work incredibly rewarding. Patients are incredibly grateful for the care, and most people actually don’t need that support. It is available for them. We encourage a lot of self-care, a lot of support within collegial groups, and we have a national group where we’re in touch with each other all the time to support each other, which is essential, but it’s been well absorbed.

Because the New Zealand Medical Association here has a stance against euthanasia, I mean, did this issue at the time of debate when it’s coming through drive a wedge through the medical profession?

I don’t think so. I think that the Canadian Medical Association has had a neutral opinion about this in an effort to support all 85,000 members of our association, because there is, obviously, a wide variety, but I don’t think there was a wedge. I think there was a bit of a fear at the beginning. A lot of physicians didn’t understand what this was or how to do it. A little bit scared to step into that space. The very few who did step forward banded together very quickly in our organisation, and we’ve built a really strong network of support for each other. So I don’t think ‘wedge’ is the right word.

It’s three years on. No law is perfect, I guess. Do you believe that Canada’s law could work better?

Actually, I have to say that Canada’s law is working really really well. There’s obviously people on both sides of the debate saying it’s not liberal enough or it’s already too restrictive. There’s lots of debate. But it’s quite rigorous. The eligibility criteria have stood for three years. There’s no rollback, there’s no location locally, provincially or nationally looking to expand that. It’s holding well. I think that there’s a number of safeguards in place that are holding, and I think there’s absolutely no evidence of any sort of misuse. There’s been no charge of any clinician.

Okay, so you say that the safeguards are in place. In particular, what are the safeguards that you support that are in place?

There’s a number of safeguards in place. Whether I support them or not we could talk about another day. But a patient needs to give consent both previously when they have a written consent. They actually need to give consent at the moment of the death. So it has to be the patient themselves. There’s a 10-day waiting period reflective to think about their decision, to discuss it with family and have other opinions involved. There’s lots of safeguards. There’s many more.

You talked before about the legislation being reasonably stable, but there is debate in Canada at the moment about whether to increase it, and there have been reports on whether mature minors should be accessible.

I’m really glad you asked me. This is a misrepresentation of the facts of Canada. There is absolutely, in no jurisdiction in Canada, any current move to expand our eligibility criteria. Let me make that very very clear. Including mature minors. So if you just give me exactly 30 seconds, it used to be that there was a blanket ban on assisted dying in Canada. The highest court in our country carved out an exception where that could be legalised, and then the government legislated a law which is more restrictive than that, which is our current law for MAID in Canada. There is current debate. There are two court challenges challenging the restricted law to put it back to the High Court’s definition of criteria, and whether that does or doesn’t happen, it was yet to be seen. But other than that, there’s no expansion of any criteria. The issue of immature minors, which has been raised in your media, is an issue which has been discussed well before our law, during the law, and currently there’s a group of academics that have written a report about the issue of whether… Actually, the report is a collection of international data about the issue of mature minors and euthanasia. It makes no recommendation to government, and there’s no government anywhere considering expanding our law to include mature minors at this time.

So you believe that this has been misrepresented by anti-euthanasia advocates over here?

Absolutely.

Okay. What about our law? Have you had any experience or have you looked at our law and do you see any problems with it, our proposed law?

I’m not going to comment on the New Zealand legislation that’s been proposed. I think that there is a lot of similarities, from what I’ve read, to the Canadian law. There’s also some significant differences – most significantly, I believe that there’s going to be a move towards making it restricted to terminal illness with the prognosis of six months. It’s very very different to Canada.

In Canada, it’s what?

In Canada, one of the criteria is that the natural death of the patient must be in what’s called the reasonably foreseeable future. And that is a bit of a vague term that required some time to get used to interpreting. We now have a better idea, but there’s nowhere about terminal illness or a particular time.

Would it make it easier for you if you had those kinds of restrictions that are proposed here?

No, I don’t think so. I think that would be… I think the idea of terminal illness in six months is very very restrictive and really cuts out a significant group of people that are suffering intolerably.

And those kinds of prognoses are often wrong, aren’t they?

They are. We’re not very good at that.

Okay. What about a couple of other issues that get raised here. What about the issue of coercion, that somebody is vulnerable and in a vulnerable state and they don’t want to be a burden to their family and are coerced into electing this? Have you seen that?

I actually haven’t seen that at all. I think it’s a bit condescending to people to tell them that they can’t make up their own mind. It’s part of my job to ensure that there is no coercion – both external or obvious coercion or even subtle coercion. And I always speak to patients privately and alone and have a conversation with them. I take that very very seriously. But every physician every day in their practice talks to patients about capacity and consent and coercion. They don’t use those words, but that’s exactly what they’re doing. So when people tell me that I’m challenged to do that properly, I think that’s a little bit insulting, and I certainly do know how to do my job.

Okay, and one last question. So since it’s been in place, about 8000 people up to the end of last year have taken advantage of this legislation. Has there been an increase, a jump in numbers as they years have gone past? You’re talking about 1.5 per cent of the deaths in Canada being assisted. Is that a jump? Has it been going up?

Well, it’s been going up because basically to use kind of a vulgar analogy, there’s a new product in town. It takes time for people to understand it’s available, it’s legal and it’s available in their place and how to access it, so of course the numbers are going to increase slowly over the first couple of years. This is exactly what happened in Europe. The numbers are exactly what we expected in the first couple of years. It’s still very little. It’s still about a third of what’s happening in the Netherlands. I do expect we’re going to see an increase still in Canada. I don’t think we’ve plateaued yet, but we’re getting there.

Okay. Dr Stefanie Green, thank you very much for your time this morning.

Today marks the coming into effect of Victoria’s Voluntary Assisted Dying Act 2017. From today, Victorians at the end of a terminal illness who meet strict eligibility criteria will be able to access assistance to die.

The End-of-Life Choice Society in New Zealand congratulates the state of Victoria for arriving at the culmination of its process with this legislation.

“Victoria is the first state in Australia to reach this point, but other states look as if they are following,” said Maryan Street, President of the New Zealand End-of-Life Choice Society.

“Their MPs have gone through a very similar lengthy process to ours, with a select committee producing a very good report which recommended the passage of their law, with its 68 safeguards.

“In a week, our MPs will have a chance to vote on the second reading of David Seymour’s End of Life Choice bill. Let’s hope they recognise the 74% of New Zealanders who support or strongly support a law similar to Victoria’s.

“All we want is the choice, when we are in the end stages of a terminal illness, to die on our own terms under lawful and regulated conditions. We don’t prescribe it for everyone – we just want people to have the choice if they meet certain criteria.

“Laws like this can work well and are doing so around the world, including now, in Victoria,” said Maryan Street.